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Management and Network Services, LLC
Credentialed Provider Manual
Revised June 2014
Credentialed Provider Manual
An overview of MNS services and products
Making Managed Care Manageable
Management and Network Services, LLC
Credentialed Provider Manual
Dear Affiliated Provider,
Welcome! You are a valued member of a preferred group of quality driven, market savvy, skilled nursing
facility operators who realize the basic benefit of working together geographically to serve and attract
community-based managed care patients.
MNS prides itself on being a friendly, dynamic team committed to making your membership a successful
experience in a challenging environment. We recognize that your dedication to serving your community
is paramount—and it’s our job to help you discover additional ways of doing so.
The management team of MNS is here to serve you in the following areas:
 Education
 Contracting Access/Placement Credentialing
 Care Coordination Services
 Marketing
 Accounts Receivable Management
The purpose of the MNS Credentialed Provider Manual is to give you an overview of MNS services and
processes and provide you with answers to some basic questions. However, if additional questions from
either you or your staff should arise throughout the course of our relationship, please contact us! We are
always available and eager to answer your questions or assist you with your marketing efforts.
Yours in Service,
Jon Hoffman
Jon Hoffman
Chief Executive Officer
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Table of Contents
Introduction
5
MNS History and Ownership
5
MNS Philosophy
6
MNS Hours of Operation and Contact Information
7
Quality Programs
8
Credentialing
8
Re-credentialing
9
State Survey Review
9
Special Studies
9
Affiliated Provider Profiles
10
Special Reports
10
Special Surveys
10
Satisfaction Surveys
10
Contracting
11
Affiliated Provider Selection
11
Master Contract
11
Selection of Payor Contracts
11
Termination of Payor Contracts
12
Insert MNS/Affiliated Provider Agreement and Payment Plans here
13
MNS Payors and Markets
14–17
Marketing
18
Affiliated Provider Staff Education/Internal Marketing
18
Community Presentations
18
Relationship Building
18
Care coordination Services
19
Overview
19
Skilled Services—Access and Admission Process
19
Skilled Services—Initial Information Required for Admission
21
Care Improvement Plus Precertification Checklist
22
Texas Precertification Checklist
Humana Billing Communication Form
Evaluation Information Required
23
24
25
Managed Care Level of Care Documentation Guidelines
Patient Updates
3
26–27
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Table of Contents
Benefit Form
29
Skilled Pre-Cert/Re-cert Form
30
Change in Condition and Incident Reporting
31
Discharge Summary
31
Skilled Discharge Planning Form
32–34
Clinical Evaluation Update Form
35–41
United Healthcare Referral Process
42
United Healthcare Documentation Form—Skilled
43
United Healthcare Documentation Form—Outpatient
44
Referral for Part B Services or Outpatient Services
45
Medicare Exhaust Patient Processing
45
Medicare 100-Day Exhaust Claims and Charts Checklist
46
PCP Discharge Appointment Program
47
Notification Form for Physician Follow-up Appointment
48
Aetna Home Health Initiative
49
Aetna Welcome Home Program
49
Medicare Advantage Private Fee for Service (PFFS) Admissions
50
Notice of Medicare Non-Coverage Letter (NOMNC)
50
Example of Notice of Medicare Non-Coverage
51–52
Reimbursement
53
Claims Submission
53–57
Sample Aetna Utilization Report
58
Sample Provider Census Report
59
Sample UB-04—Private Fee For Service Claim
60
Sample UB-04—Per Diem Claim
61
Sample UB-04—TPN Claim
62
Sample UB-04—Part B/Outpatient Claim
63
Sample UB-04—Pharmacy/Exclusion Claim
64
Glossary
65
Quick Reference—MNS
70
Quick Reference—Texas
71
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Introduction
MNS History and Ownership
Management and Network Services (MNS) was founded in 1996 by an independent provider of
pharmacy and ancillary services to long-term and acute-care facilities based in Cleveland, Ohio. MNS
recognized the need to create a service to support affiliated Medicare certified skilled nursing providers in
their work to operate independently in an increasingly competitive managed care environment.
The first contract MNS negotiated was with a major national payor; the contract enabled MNS to provide
statewide rural coverage for their commercial products throughout Ohio. Coverage soon expanded
statewide to include urban areas and Medicare products. The initial operations team developed cuttingedge information systems that had the capability to track managed care patient data. Additionally, the
team developed an affiliated provider credentialing program which qualified MNS for subcontracted
delegated skilled nursing provider credentialing. The team marketed the concept to other payors,
negotiated contracts and developed a network of affiliated providers (facilities) that would satisfy the
demands of a dynamic payor market.
In January 1997, MNS became Management and Network Services of Ohio, LLC. The new Board of
Managers was comprised of leading industry experts in a variety of fields, including skilled nursing facility
operations, physician practice consulting, accounting, healthcare law and business. Today, MNS is privately
held by TRW Investments and Omnicare. MNS strives to remain apolitical, with the quality of patient care
and service to its providers taking precedence over nursing home ownership, management changes and
politics.
CasePointe
In December 2003, MNS began utilizing CasePointe, a proprietary software program designed by Pointe
Blank Solutions (www.pointeblank.net). Drawing on all that had been learned in the provider and insurance
markets during the previous years, the CasePointe system was developed to more efficiently manage the
operations of the Network. The software manages and tracks Medical Records, Care Coordination, Provider
Networks, Credentialing, and Claim Processing—and has Integrated Document Imaging capabilities.
Additionally, CasePointe provides web-based reporting that includes payor specific inpatient census and
cost reports, top 25 primary diagnoses for inpatients, top 25 hospital referrals based on total inpatient cost,
top 25 admitting facilities based on total inpatient cost, payor-specific provider directories, and facility
profiles by county.
LEAN
In 2006, MNS elected to focus on the quality of customer service processes by instituting the LEAN
program. The integration of LEAN business principles across all MNS departments reinforces the
organization’s core values and encourages staff to strive for client satisfaction by providing exemplary
customer service.
MNS participated in the development of new medical protocols derived from a medical study conducted by
a major payor in 2007. As a result, MNS and its providers instituted new procedures to benefit those who
use skilled services for short-term rehab. These studies are possible because of MNS’ ability to reach out to
hundreds of providers with a common process, resulting in measurable outcomes.
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Beginning in November 2007, CasePointe was upgraded with a superb electronic billing and claims
management package, enabling an efficient and prompt turnaround of provider claims. The upgrade also
allowed MNS to monitor provider submission and payor turnaround times.
Service
Since its inception, the goal of MNS has been to serve affiliated providers as well as contracted payors with
excellence in customer service. The company vision is to support the overall healthcare system by
eliminating managed care task redundancies for the affiliated provider, while reducing the stress for
patients and families attempting to locate suitable bed. With the complexities of managed care simplified,
MNS providers can focus on offering quality patient care.
MNS has also instituted a contract administration program that will allow MNS to manage all of a facility’s
managed care contracts—both the MNS contracts and any direct payor contracts that the facility may have.
This allows for one point of contact for all managed care admissions. MNS can utilize its proprietary
software to house all of its clients managed care contracts, allowing for efficient management of benefits,
precertification, and claims processes.
Today Management and Network Services operates as a full-service, messenger model network of affiliated
providers with national and regional contracts. MNS serves the needs of commercial insurers, self-insured
networks, third-party administrators, and Medicare and Medicaid Contractors in 37 states across the
country.
MNS is headquartered in Dublin, Ohio, a suburb of Columbus, with additional offices in Northeast Ohio,
Texas, and Colorado. Please feel free to contact us regarding our services. We look forward to serving you!
MNS Philosophy
VISION MNS supports the overall healthcare system by eliminating managed care
task redundancies for both the affiliated provider and the healthcare payor while
reducing the stress for the patient and family attempting to locate a suitable bed.
PRINCIPLES MNS builds co-operative relationships and enhances communications
between payors, providers, and beneficiaries.
GOAL MNS provides quality, post acute care at a reasonable cost, while focusing on
patient choice and satisfaction.
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With MNS, Providers benefit from:
 Lower administrative costs associated with marketing, contracting, care coordination services,
billing, and A/R management
 Prompt payment, enhanced managed care, A/R collections and management
 Access to a large pool of payors
 Marketing to hospitals, insurance companies, and HMOs
 Continuous managed care relationships regardless of facility personnel changes
With MNS, Payors benefit from:
 Lower administrative costs associated with contracting, credentialing or NCQA, care
coordination services, claims processing, customer service, and payment
 Education regarding skilled care regulations and operations
 Prompt transfer or direct admissions to quality, credentialed facilities
 Centralized information flow regarding billing, management reports, and quality
studies
 A single contact for complaint resolution and reporting
MNS Hours of Operation and Contact Information
Hours of Operation
MNS staff is on duty from 8:30 AM to 6 PM EST Monday through Friday.
On-call 24/7 placement service includes weekends and holidays and provides for admissions via a central
intake number connected to a care coordinator equipped with a cell phone and laptop computer with
access to the main database.
Current Contact Information:
Management and Network Services, LLC.
5555 Parkcenter Circle, STE 200
Dublin, OH 43017
Phone: 800-949-2159
Fax: 800-949-2551
www.mnsnetwork.com
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Quality Programs
Credentialing
Insurance companies are periodically surveyed by NCQA which gives them a quality seal of approval.
Contracting with “credentialed” facilities is necessary in order for the Plans to gain NCQA approval—this
is as important to them as HCFA surveys are to all our members. Each facility is credentialed prior to
becoming an affiliated provider in the MNS network and prior to the execution of a Network Agreement.
The MNS credentialing procedures have been thoroughly reviewed and are audited annually by several
major insurance companies who have granted MNS “delegated credentialing status.”
The MNS credentialing process involves the following:
1. Review of the Request for Information (RFI)
2. Desk or Onsite assessment by an MNS representative may include:
a. MNS Data Collection Tool
b. Review of operations (clinical and management), customer satisfaction, resident council meeting
minutes, and credentials of the Medical Director ensuring oversight of facility by a qualified
physician
c. A tour of the building to observe the facility environment
d. Interviews with key staff members
e. Review of policies
f. Review of Infection Control Programs and Exposure Plan
g. Review of the Fire Safety and Disaster Plan
h. Review of fire drills for six (6) months (one per shift per month)
i. Review of in-services for the past year
j. Review of the dietary operation to observe all dietary practices
k. Admission packet review and Resident Rights notice
l. Chart review
m. Quality Indicators
n. Other items as required by specific Plans
3. MNS Credentialing Committee then reviews the facility information, including:
a. Current Certificate of Insurance for Liability Insurance
b. CMS survey
c. Medical Director qualifications
d. Therapist qualifications
e. Current staffing information
f. State nursing home license of operation
g. Changes in facility management or ownership
h. Changes in operations
i. Facility’s performance during the membership period
j. Other certifications
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Re-credentialing
Re-credentialing will occur every three years at a minimum. The re-credentialing survey consists of:
1. Desk review or onsite assessment by an MNS representative
2. Review of facility file for current information/documentation of:
a. Certificate of Insurance for Liability Insurance
b. CMS survey
c. A copy of the most recent Medicare recertification letter
d. Medical Director qualifications
e. State nursing home license of operation
f. Changes in facility management or ownership
g. Changes in operations
h. Facility’s performance during the membership period
i. Other certifications
j. Quality Indicators
k. Facility Attestation
l. Review of OIG/OPM and EPLS information to ensure facility does not appear on these listings
The MNS Credentialing Committee makes the final decision concerning a facility’s initial or continued
participation in the MNS network. The facility will be informed by MNS on their status of the application
and re-credentialing process.
State Survey Review
The MNS membership agreement requires facilities to forward the most recent state survey and CMS
recertification letter to the MNS Compliance Department upon receipt. PDF copies of these documents
should be faxed to 614-789-2065 or e-mailed to [email protected]. The agreement also
requires that MNS be notified of—and forwarded a copy of—any complaint surveys that are received.
Special Studies
Satisfaction Surveys
1. Affiliated Provider (Facility)
Network affiliated providers will be requested to complete an annual satisfaction survey of the MNS
services provided. Prompt response is expected. Survey results are reviewed by MNS staff and kept on
file for MNS use in ongoing customer service improvement processes.
2. Ongoing Evaluation
MNS care coordinators monitor each affiliated provider’s care delivery as evidenced by medical
update reports. If there is a concern or complaint about care in documentation, patient/family reports,
insurance case manager reports, or community reports, the concern/complaint will be escalated to
MNS’ Vice President of Care Coordination for review. It may then go to the MNS Quality Committee if
needed.
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Affiliated Provider Investigation may include but is not limited to:
a. Verbal review of case/ incident
b. Requested written review of incident and action for correction
c. Onsite review by an MNS representative
If warranted, the affiliated provider will receive a written notification o f suspension from the network
until the issue is resolved. If an onsite investigation is warranted, the investigation will be conducted by a
licensed health care professional (Reviewer) of MNS’ choosing, within five business days of the
determination of need. The Reviewer will submit a written report to the Quality Committee for review.
The Quality Committee may reinstate the provider or may conclude that the provider should be removed
from the network. Written notification of the decision will be sent to the provider.
Appeals Process
If the provider disagrees with the Quality Committee’s decision, it may apply for an appeal by submitting a
written request to MNS within 30 business days from the receipt of notification of termination/suspension
detailing the issues of grievance or disagreement. MNS will contact the provider within five business days
from receipt of the appeal and may request further documentation, onsite review, and/or a meeting to
discuss the concerns. Additional information will be presented to the Quality Committee within 30 business
days of investigation. The facility’s identification will not be made known to the Quality Committee. A final
determination will be made by the Quality Committee. Written notification will be sent to the provider
within five business days following the appeal hearing.
Affiliated Provider Profiles
In order to maintain a current database of facility information, MNS will annually request the facility
administrator submit an updated facility profile.
Special Reports
As a network affiliated provider, you may be requested to participate in special surveys relating to skilled
patient placement and care. All information from an affiliated provider’s participation is held in confidence by
MNS as agreed upon in the MNS Membership Agreement.
Special Surveys
Some of the insurance contracts available to the affiliated provider through the MNS network allow the
insurance company to request to perform an onsite survey for credentialing or medical record review
purposes. An insurance company and/or MNS representative will notify the affiliated provider to make
arrangements for an onsite visit by representatives of the insurance company.
Satisfaction Surveys
MNS conducts customer satisfaction surveys with the patient while he/she is at the facility. An MNS
representative completes a customer satisfaction survey that is summarized and sent to the President,
Director of Provider Relations and Director of Business Development for review.
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Contracting
Affiliated Provider Selection
MNS’ contracting goal is to provide county access for each insurance payor as needed. In urban areas, MNS
enrolls affiliated providers based upon payor market demand. In rural areas, MNS enters the market only if
beneficiaries reside in that market. This demand is dynamic since payors initiate or withdraw member
products based on past successes or expected market performance.
Occasionally, MNS is directed to enroll specific affiliated providers by individual payors. This results in
“select networks” within the greater MNS network. At every opportunity MNS offers the entire network to
its payor contracting community.
MNS is independent and does not own, operate, or manage facilities. MNS serves for-profit, not-forprofit, privately owned, and corporately owned facilities. In order to operate in certain states, MNS has had
to institute application and membership fees. If your state operates with such a fee then the policy
regarding such follows the “Agreement for Membership Services.”
Facilities must pass MNS’ critical criteria as described in the Quality Programs section of this manual to be
considered for membership in the MNS network. Occasionally an insurance contract may require a facility
to meet a standard higher than MNS’ credentialing criteria.
Master Contract
Every affiliated provider executes a master contract with MNS. This contract delineates the responsibilities
of both MNS and the provider.
These responsibilities include but are not limited to:
 Submission and payment of invoices
 Selection of payor contracts
 Participation in quality programs
Selection of Payor Contracts
Each affiliated provider, upon joining the MNS network, has the opportunity to select any or all payor
contracts that are available in their service area. After reviewing the contracted rates, the affiliated
provider simply signs the rate sheet indicating they would like to participate, returns the signed sheet to
MNS, and may begin accepting patients upon notification by MNS that the facility has passed credentialing.
There are, however, a few exceptions. MNS has some managed care contracts that require a separate
application and/or enrollment process in order to participate in their network. The enrollment process still
involves reviewing the rates, signing the rate sheet and returning the signed sheet to MNS. The key
difference is that the provider cannot begin accepting patients until they have been notified by MNS that
their request to join that particular managed care network has been accepted. NOTE: Payors can elect to
utilize the entire network or selected providers to supply services.
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A provider may choose to negotiate directly with a payor that they are already working with through MNS
if—and only if—the provider cancels their current payor contract with MNS. If a provider chooses to belong
to other networks, they may do so. Note, however, that the provider may not have multiple contracts for
the same payor and is obligated to notify MNS before the provider begins negotiations with a contracted
payor.
MNS regularly monitors existing payor contracts and actively markets to new payors for additional
contracts. As contracts are negotiated and renegotiated, MNS sends rate sheets to network affiliated
providers so they may choose which contracts they wish to participate in through MNS.
MNS has also instituted a contract administration program that will allow MNS to manage all of a facility’s
managed care contracts, including both the MNS contracts and any direct payor contracts that the facility
may have. This allows for a single point of contact for all managed care admissions. If you are interested in
discussing the possibility of MNS managing your existing direct contracts as well, please contact the MNS
Business Development Department at 800-949-2159.
Termination of Payor Contracts
Upon termination of the provider’s participation status with any payor, the provider shall promptly notify
any Plan members that are currently receiving treatment at the facility of the effective date of
termination.
MNS regularly monitors existing payor contracts and actively markets to new payors for
additional contracts. As contracts are negotiated and renegotiated, MNS sends rates
sheets to network affiliated providers so they may choose which contracts they wish to
participate in through MNS.
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Affiliated Provider Personnel
(INSERT A COPY OF YOUR MNS/AFFILIATED PROVIDER AGREEMENT SIGNATURE PAGES
AND PAYMENT RATES HERE.)
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MNS Payors and Markets (March 2014)
Payor
Market Area
Provider Panel Status
Aetna
Traditional
Commercial
Elect Choice
Open Choice
Select Choice / HMO
Managed Choice
Medicare
Medicare Advantage
Golden Medicare PPO
Local Medicare PPO
Exchange
QHP
AHS—Tulsa Oklahoma Health Plan
Medicare Advantage
NC—CO, IL, IN, KS, *KY, MI, MO, OH, OK, SD, TX,
*UT, *WI
Open
OK—Select Counties
Closed/Select
Amerigroup
Medicare Advantage
Medicaid
Beech Street/Concentra
Commercial
PPO
Workman’s Comp
Buckeye
Medicaid
Medicare
Exchange
MyCare Ohio
Care Improvement Plus
Medicare Advantage
TX
Open
National
Open
OH
Open
AR, GA, IA, IL, IN, MD, MO, NM, NY, PA, SC, TX,
VA, WI
Open
CareSource Ohio
Medicare Advantage
Medicaid
MyCare Ohio
CHCS
Long-Term Care
OH
Open
*Requires separate application and
approval
National
Open
*Requires CMS 3 Star Rating or higher
Cigna
Commercial
Select HMO
Open Access
AR, IL KY, MS, OH, TN, WI, SC, NC
Closed/Select
*Requires separate application and
approval
Cigna-HealthSpring
Medicaid
TX—Select Counties
Open
Cleveland Health Network
Commercial
Cleveland Clinic Employees
Metro Health Employees
Cleveland
Closed/Select
Cofinity
CO, IL, IN, MI, OH, WI
Open
Consumer’s Life—(Medical Mutual)
Commercial
Traditional
SuperMed Plus (PPO)
SuperMed Classic (PPO)
HMO Health Ohio
SuperMed HMO
IN
Closed/Select
SE—AL, AR, DC, FL, GA, LA, MS, NC, SC, TN, VA,
WV
*Select Counties
Open to MNS
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MNS Payors and Markets (March 2014)
Payor
Market Area
Provider Panel Status
CorVel
RHI
Mercy Health Partners
PPO
Workers’ Comp
Emerald Health Network
Commercial
PPO
(Accessed through HealthSmart Agreement)
National
Open
OH
Open
Galaxy Health Network
Commercial
PPO
OH, IN, KY, WI, MI, PA, IL, CO, MO, KS
National
Open
The Health Plan
Commercial
Medicare + Choice
PPO
HealthSmart
HealthSmart Preferred Care
Interplan Health Group (IHG)
Emerald Health Network (Ohio)
Preferred Plan Inc. (Illinois)
Accel
Health EOS
OH—Select Counties
Closed/Select
*Requires separate application and
approval by Health Plan
National
Open
MI, MN, WI
(Accessed through MultiPlan Agreement)
Humana
All Products
National
Closed/Select
*Requires separate application
MultiPlan
PPO Network
(Includes PHCS in CO, IL, IN, KY, MI, MO, OH, SC)
National
Open
National Preferred Provider Network (NPPN)
PPO Network
National
Open
Ohio Health Choice
OH, Northern KY, Southeast IN
Open
*Requires separate application
Ohio Preferred Network
PPO Network
OH
Open
PHCS
(Accessed through the MultiPlan Agreement)
National
Open
PHCS Savility
Commercial
Workers’ Compensation
AR, CO, DC, IL, IN, KS, KY, MD, MI, MS, MO, OH,
OK, SC, TN, TX, VA, WI
Open
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MNS Payors and Markets (March 2014)
Payor
Market Area
Provider Panel Status
IL
Preferred Plan, Inc.
(Accessed through the HealthSmart Agreement)
Scott & White Health Plan
Medicare Advantage
Select Counties in TX—Bell, Bosque, Brazos,
Burleson, Collin, Coryell, Dallas, Denton, Ellis,
Falls, Freestone, Grimes, Hamilton, Hill, Johnson,
Kaufman, Lampasas, Limestone, Madison,
McLennan, Milam, Mills, Robertson, Rockwall,
San Saba, Somervell, Tarrant, Washington
Select
*Requires separate application
SummaCare
OH—Selected Counties
Open
*Requires separate application
United Healthcare Community Plan (Formerly
Unison)
Medicaid
OH—Selected Counties
Open
United Healthcare
Commercial
HMO, PPO, POS
Medicare
HMO—Evercare
OH, KY, MI, PA, IN
Closed/Select
USA MCO
Commercial
Medicare Advantage
Workers’ Compensation
National
Open
WellCare
Medicare
Medicaid
Harmony (IL, IN, MO)
HealthEase and Staywell (FL)
(Agreement is National)
Medicare Plan in: FL, GA, HI, IL, MO, LA, KY, NJ,
OH, TX, AZ, CA, CT
Open
*Requires separate application
Windsor Sterling
HMO/PPO/PFFS
AR, MS, SC, TN (Agreement is National)
Commercial
SCPremier, SCPrime, Mercy Choice,
SCPlus, SCSelect
Medicare
SCSecure, SCSupplemental Standard,
SCSupplemental Select
Medicaid Plan in: FL, GA, KY, HI, IL
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MNS Payors and Markets (March 2014)
MNS Payors—Summary
Aetna
Consumer’s Life—(Medical
PHCS
AHS—Tulsa Oklahoma Health Plan
CorVel
PHCS Savility
Amerigroup
Emerald Health Network
Preferred Plan, Inc.
Beech Street/Concentra
Galaxy Health Network
Scott & White Health Plan
Buckeye
The Health Plan
SummaCare
Care Improvement Plus
HealthSmart
United Healthcare Community Plan
CareSource Ohio
Health EOS
United Healthcare
CHCS
Humana
USA MCO
Cigna
MultiPlan
WellCare
Cigna-HealthSpring
National Preferred Provider
Windsor Sterling
Cleveland Health Network
Ohio Health Choice
Cofinity
Ohio Preferred Network
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Marketing
Affiliated provider Staff Education/Internal Marketing
New affiliated providers with MNS will be offered an in-service overview of MNS operations, a review of this
Provider Manual, as well as an overview of managed care in general.
MNS recommends that in-service participants include the Administrator, Director of Nursing, Admissions/
Marketing personnel, as well as the Business Manager and Case Manager, if available.
Affiliated providers must determine their internal educational needs regarding managed care. Generally
speaking, when more staff is involved with managed care, better external marketing can be developed.
MNS staff will contact providers periodically to check on the staff’s educational needs. Likewise, providers
are encouraged to contact MNS at any time an in-service or further education is needed. Please contact the
MNS Provider Development Department at 800-949-2159.
MNS also publishes a newsletter for affiliated providers to distribute to key staff members.
Community Presentations
Although MNS conducts extensive marketing efforts, affiliated providers are strongly encouraged to
promote their own facility and the network by distributing MNS published materials available from MNS.
Relationship Building
MNS will work with insurance payors, hospitals, and physician groups on behalf of affiliated providers.
However, individual affiliated providers should continue to build and maintain community awareness of
their participation in managed care contracts. The provider’s “community” includes hospitals, employer
groups, senior citizen centers, physician groups, civic groups, and other professional healthcare
organizations. The importance of relationship building within the community cannot be stressed enough.
For assistance developing a marketing plan, marketing material, or a managed care program, please contact
the MNS Provider Development Department at 800-949-2159.
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Care Coordination Services
Overview
MNS employs a professional team of nurse care coordinators and administrative assistants. The care
coordination team is located at the MNS headquarters in Dublin, Ohio. Care coordination services are
available 24 hours a day, 7 days a week. The Care Coordination department is staffed in the office during
regular business hours of 8:30 AM to 6:00 PM EST Monday through Friday and via an on-call system after
business hours weekdays, weekends, and holidays.
In order to serve all clients more efficiently, MNS has a designated Care Coordination Call Center. To access
the network for patient placement questions, updates, or discharge information, call 800-949-2159, Option
#4. Follow the prompts accordingly. When the case is received, it will be assigned to a Care Coordinator or
Assistant who will work with you during the patient’s stay. MNS Care Coordination can also be reached via
fax at 614-789-2060 or e-mail at [email protected]. Texas referrals can be forwarded via fax at
614-339-4311 or e-mail at [email protected].
The Care Coordination Department process includes the following main components:
1. Network and affiliated provider access and admission process
2. Obtaining initial information required for benefit verification, admission, and preauthorization of
affiliated provider skilled admission
3. Obtaining required evaluation information for additional authorization of skilled stay and supporting level
of care
4. Patient update for continued skilled authorization
5. Change in condition and incident reporting that may affect the skilled stay
6. Discharge planning summary including patient follow-up in the community as applicable
7. Facilitate the delivery of denial of services from the insurance payor
8. Referral for Part B or outpatient services
9. Medicare exhaust chart and bill submission
Skilled Services—Access and Admission Process
1. Insurance company case manager, hospital discharge planner, or a provider representative contacts MNS
for patient placement at 800-949-2159, Option # 4.
2. MNS checks member eligibility and benefits.
3. MNS checks provider bed availability and capability of accepting the patient.
4. Patient and/or patient’s family is informed of provider availability via the hospital discharge planner or
social services at the discharging facility.
5. MNS contacts admitting provider concerning patient placement and requests preauthorization
information required from the hospital or discharging facility.
6. MNS reviews Skill Level (Level I, II, III, IV or Part B) in consultation with the provider using hospital
discharge information. MNS requests insurer to approve Skill Level and admission.
a. Skill level is based on patient’s skilled needs
 PT, OT, ST, IV therapy
 Respiratory Therapy
 Nursing Interventions
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7. Admitting provider assesses patient for admission. Provider determines facility’s ability to care for
the patient and reports to MNS.
8. Skilled level is confirmed based on actual patient evaluation, assessments, and plan of care. This
determination varies based on insurer and product.
9. MNS completes and forwards the Skilled Pre-cert/Re-cert Form to provider contact.
10. Provider and hospital complete transfer arrangements.
11. Patient is admitted and provider notifies MNS of the actual date of admission.
12. Provider completes patient evaluation. Electronically fillable MNS Clinical Evaluations and Updates
Forms, and MNS Skilled Discharge Planning Forms can be downloaded from the MNS website. Access
the Provider Tab, download, and save the forms to your computer. The forms can then be completed
and faxed to MNS. Forms must contain the following information, and are to be faxed on the specified
day as determined by the insurance payor:
a. Evaluations
b. Goals
c. Assessments
d. Admission Orders
e. Preliminary discharge planning of patient
13. Level of care will be reviewed and confirmed for accuracy based on the assessed and planned patient
needs and treatment.
MNS employs a professional team of nurse care coordinators and administrative assistants. The
care coordination team is located at the MNS headquarters in Dublin, Ohio. Care coordination
services are available 24 hours a day, 7 days a week. The Care Coordination department is staffed
in the office during regular business hours of 8:30 AM to 6:00 PM EST Monday through Friday and
via an on-call system after business hours weekdays, weekends, and holidays.
Note: Benefits/precertification is subject to insurance company availability.
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Skilled Services—Initial Information Required for Admission
[See Precertification Checklist, next page]
The following contains initial information required for admission:
1 . Fill in patient name, date of birth, name of the admitting facility, facility phone number, facility contact
name.
2. Indicate the anticipated date of admission.
3. Include a face sheet with the following demographic information on patient and member carrying the
insurance:
a. patient name
b. insurance coverage
c. member’s name who holds the insurance if different from the patient and date of birth
d. identification numbers/group number/social security number
e. date of birth
f. patient’s address/phone
g. most recent hospitalization and admit date
h. patient diagnosis for admission
i. skilled needs
4. Copy of patient insurance card (front/back)
5. Most current history and physical
6. Name of physician treating/covering the patient at the SNF
a. full name of the doctor
b. doctor address
c. doctor phone number
d. doctor NPI number
7. Most current therapy notes needing the following:
a. must be within the last 24 hours
b. current functional status
c. anticipated skilled needs
d. anticipated length of stay
e. home demographics
f. prior level of function
g. assistance needed
8. Medications: IV meds, TPN, IM/SQ injections ordered for SNF
9. Wound description
a. location
b. stage
c. measurements
d. treatment orders
e. wound VAC
10. Respiratory report:
a. vent settings
b. frequency of trach suctioning
c. weaning orders
d. oxygen % or liters needed
11. Nutrition: PEG feeding tube orders
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MNS is committed to serving our facilities in the best manner possible. Included is
the information needed to precertify a patient for skilled status. We ask that you edit
the hospital information and send only the forms described below. If you have any
questions, please contact Care Coordination @ 800-949-2159 Option 4.
CARE IMPROVEMENT PLUS PRECERTIFICATION CHECKLIST
Patient Name
DOB
Name of Admitting Facility
Phone#
Name of Facility Contact
In order to precertify a case for skilled status, please check and fax to MNS the following information with this checklist.
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Anticipated date of admission and facility face sheet ________________________________________________
Face sheet to include demographics and insurance information
Most current H & P (History and Physical)
Documentation from Social Worker at Hospital stating patient is aware of Transition to SNF
Hospital Discharge Planner Name and Phone Number _______________________________________________
PCP Name and Phone Number __________________________________________________________________
All therapy notes with last note within the last 24 hours. Please include home demographics and1 prior level of function / assistance needed.
Medications: Current medication list including- IV meds, TPN, IM/SQ injections ordered for SNF
Physician order to transfer patient to SNF
Wound description: location, stage, measurements, treatment orders, Wound VAC
Respiratory Report: Vent settings, frequency of trach suction, weaning orders, Oxygen % or liters needed.
Nutrition: PEG feeding tube order
Name of the physician treating/covering patient at SNF
Full name, address, phone and NPI #
Dr. _________________________________________________________________________________________
Please DO NOT send operative notes, medication administration records, fall risk, hospital labs, and multiple consults. Please include facility face sheet.
Please send ONLY ONE patient per fax per HIPPA regulations.
Please fax information to Care Coordination
614.789.2060
The above information should not exceed 12 pages.
Thank you for your assistance in expediting this skilled admission documentation review.
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MNS is committed to serving our facilities in the best manner possible. Included is
the information needed to precertify a patient for skilled status. We ask that you edit
the hospital information and send only the forms described below. If you have any
questions, please contact Care Coordination @ 800-949-2159 Option 4.
TEXAS PRECERTIFICATION CHECKLIST
Patient Name
DOB
Name of Admitting Facility
Phone#
Name of Facility Contact
In order to precertify a case for skilled status, please check and fax to MNS the following information with this checklist.
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Anticipated date of admission and facility face sheet ________________________________________________
Face sheet to include demographics and insurance information
Most current H & P (History and Physical)
Documentation from Social Worker at Hospital stating patient is aware of Transition to SNF
Hospital Discharge Planner Name and Phone Number _______________________________________________
PCP Name and Phone Number __________________________________________________________________
All therapy notes with last note within the last 24 hours. Please include home demographics and prior level of function / assistance needed.
Medications: Current medication list including IV meds, TPN, IM/SQ injections ordered for SNF
Physician order to transfer patient to SNF
Wound description: location, stage, measurements, treatment orders, Wound VAC
Respiratory Report: Vent settings, frequency of trach suction, weaning orders, Oxygen % or liters needed.
Nutrition: PEG feeding tube order
Name of the physician treating/covering patient at SNF
Full name, address, phone and NPI #
Dr. _________________________________________________________________________________________
Please DO NOT send operative notes, medication administration records, fall risk, hospital labs, and multiple consults. Please include facility face sheet.
Please send ONLY ONE patient per fax per HIPPA regulations.
Please fax information to Care Coordination
614.339-4311
The above information should not exceed 12 pages.
Thank you for your assistance in expediting this skilled admission documentation review.
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Humana Billing Communication Form
**Information Requested by MNS
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Evaluation Information Required
1.
2.
3.
4.
5.
6.
7.
8.
9.
Evaluations from all disciplines
Goals and plan of care for all disciplines
Actual medication list
Physician orders
Wound measurements, staging, treatment and frequency
Tube feeding, formula, rate, tolerance, and amount of p.o. intake
Patient/family plans for discharge
Any significant nursing issues
Discharge Planning
a. Caregiver capabilities
 full-time assist
 part-time assist
 sporadic assist
 alone at home
b. Home environment
 entry steps to the home
 style of home (i.e., one story, two story)
 floor of bedroom and bathroom
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Managed Care Level of Care Documentation Guidelines
Instructions: Please address all categories of care that apply and include a short narrative describing admission clinical
baseline, the current problem, treatment plan and goals for discharge. Thank you!
Managed Care Level of Care Documentation Guidelines
Documentation for Initial Nursing Admission Assessment for a Skilled Patient
Head injury
Cognition and safety deficits
Communication deficit
Clinically depressed
Pegtube—new
Foley catheter
Suprapubic catheter—new
Ostomy—new
i.e., colostomy, ileostomy,
Ileoconduit
Wounds—pressure
Wounds—surgical
Baseline status
Neurological assessment
Assessment frequency
Baseline cognition
New or chronic problem
ST evaluation or screen
ST evaluation or screen
Psych evaluation needs to be arranged.
(Check insurance plan for panel providers)
Tube placement date
Site assessment
Tolerance/residuals
Current weight
Dietary assessment
ST eval (MBS results, address dysphagia)
Current physician orders (rate, formula)
Discharge plan (long-term placement, home)
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Plan for removal
Bladder training plan
Long-term need— patient and/or caregiver teaching plan
Status of teaching plan with each update
Current orders
Initial treatment plan
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Output amount, characteristics
Type of appliance
Wound
Psychosocial assessment
Supplies (benefits, supplier for home going)
Enterstomal therapist involvement and/or referral
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Stage
Description
Site(s)
Measurements
Treatment plan
Indicate if specialty bed/devices/chairs/other DME
Physician orders/notes showing medical management
Measurements
Description
Treatment plan
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Managed Care Level of Care Documentation Guideline, continued
NWB or limited WB
Next Orthopedic appointment date
Accuchecks AC/ HS
Need range of blood sugars
How often covered over last 7 days (sliding scale)
Physician orders/notes indicating medical management
Can patient perform the accuchecks and give self injections
Identify new or chronic diabetic
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Medication
Dosage
Frequency
Stop dates
Related diagnosis/organism being treated
Is there a need for isolation?
Initial pain management program
Level of pain on 1–10 scale
Site(s)
Medication regime / orders
Response to pain medication
Physician orders/ notes showing medical management
Weight, Height
Specialty equipment
Indicate if RT or Nursing managing treatments
Current treatment orders and frequency
Respiratory assessment with each update
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Plan for weaning
Pulse ox ranges past 7 days
Pulse ox on or off O2
Respiratory assessment
Suctioning frequency/describe secretions
Plan for weaning
Nursing and RT updates
Teaching plan for patient and/or caregiver
Status of teaching plan with each update
Current orders/vent settings
Respiratory assessment
Plan for weaning
Nursing and RT updates
IV antibiotics
Pain
Bariatric
Respiratory treatments
Oxygen
Tracheostomy
Ventilator
All updates need to include the evaluation of nursing problems and include goal revisions.
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Patient Updates
1. Fax updated therapy notes on dates determined
a. current status
b. progress to goals
c. change in goals
d. change in condition
2. Current medical condition and nursing needs
a. status of patient education
b. tube feeding status: formula and rate
c. respiratory status
d. other nursing issues
3. Wound update
a. measurements
b. description
c. treatments
d. frequency
4. Current discharge plan and time frame
a. resources and providers
c. caregiver information
Since its inception, the goal of MNS has been to serve BOTH affiliated providers as well as
contracted payors with excellence in customer service. The MNS vision is to support the overall
healthcare system by eliminating managed care task redundancies for both the affiliated
provider and the healthcare payor, while reducing the stress for patients and families
attempting to locate a suitable bed. With the complexities of managed care simplified, our
providers can focus on quality patient care.
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BENEFIT FORM
Management and Network Services, LLC
5555 Parkcenter Circle, Ste. 200, Dublin, Ohio
Phone: 800-949-2159
Fax: 800-949-2551
Facility Facility Contact
Information:
Position
Facility Name
Facility Fax Number
Case Manager
Fax Number
Patient
Patient Name
Information:
Verification: Verified On (date)
Insurance Insurance Company
Information: Skilled Facility
Deductible $ Amount
DOB
Verified By
Effective (date)
Product Type
Outpatient
/Met $
Is pre-certification required?
OOP Max $ Amount
=
/Met $
Coinsurance
Member
$ Amount Per Diem
Benefit Limit $ Amount
Life Time Max $ Amount
Co-Payment $ Amount
Admit Within
Days of Minimum
Days Hospital Stay
FACILITIES SEE BELOW
Facilities please send: Hospital Face Sheet, Insurance Card & Hospital Continuity/H&P only upon initial
admission. Please notify MNS of all admission and discharge dates within 24 hours of occurrence.
Also, please fill out the physician Information below.
Physician Physician Name
Information:
Phone Number
Address
NPI #
Initial evaluations are to be completed within 24 hours of admission.
MNS update forms are to be used for all evaluations and clinical updates. The evaluations on the MNS clinical forms and the Discharge
Planning Form are due upon completion of evaluation. A reminder for the clinical update will be faxed the day the update is due. The update is due before 12
noon EST on the due date. Please notify us to whom the request should be directed to and desired fax number.
Please forward A COPY OF THIS FORM to the Business Manager of your facility. Patients must be billed the above deductibles, co-insurance, and co-pay
amounts on a monthly basis. MNS will take adjustments for “patient responsibility” amounts up to 6 months after the last MNS remittance for this patient encounter.
**Forward all documentation that applies to the above patient.**
ALL INSURANCE DISCLAIMERS APPLY.
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Skilled Pre-Cert/Re-Cert Form
To: ___________________________________________________________
Facility: ______________________________________________________
Fax #: _________________________________________________________
E-mail: ________________________________________________________
Care Coordinator: __(MNS Care Coordinator)__
Phone #: _(800) 949-2159_______________________
Ext.: ________________________________________________
Pre-Cert/ReCert
Patient Name: _(Patient name)_______________________________
Auth#: ______________________________________________
Level of Care: __(Payor name and level of care)_____________
Rate $: _______________________________________________
Covered Days: __________________________________________________
To: ___________________________________________________
Eval/update due (fax: 614-789-2061): _______________________
Primary Dx Code: ___________________________________
Comments: _____________________________________________________________________________________________________________________
All updates are to be on MNS Clinical Update Forms with complete information including current goals. The
Discharge Planning form should be included with each update. All updates are due to MNS before 12 noon EST on
the due date. Please include the following information:
Nursing
IM/SC Med Costs/d
IVAB: Cost/d, Stop date
Pain Assessment & Management
Physician Orders (Updated)
Wound Stage/Measurements/Description/Treatment
Occupational Therapy
Current progress and revised goals
Frequency of treatment, mins/day (for level of care determination)
Target date to complete goals
Physical Therapy
Current progress and revised goals
Frequency of treatment, mins/day (for level of care determination)
Target date to complete goals
Social Service
Discharge plan, family/caregiver in the home
Financial status (Medicaid application)
Guardian/DPOA-HC DME needs
Forward all documentation that applies to the above patient!
ALL INSURANCE DISCLAIMERS APPLY
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Change in Condition and Incident Reporting
1. Report to MNS any change in status of a skilled patient
a. admission to hospital
b. decline in function
c. increase in function
d. refusal of treatment
e. inability to participate
f. transfer
g. expire
2. Report to MNS incidents
a. falls
b. medication errors
c. patient injury
d. treatment errors
Discharge Summary
1. Fax discharge notes from each discipline to MNS.
2. Send therapy time logs of services rendered to the patient.
3. Discharge plan that was implemented.
Aetna OH, IN, IL, TX Commercial and Medicare Advantage Products: Complete the scheduling of the
Primary Care Physician appointment, document the information on the MNS Skilled Discharge
Planning Form, and fax to MNS.
Aetna OH only: Complete the Home Health referral and document information on the MNS Skilled
Discharge Planning Form and fax to MNS.
Amerigroup TX: Complete the scheduling of the Primary Care Physician appointment, document the
information on the MNS Skilled Discharge Planning Form, and fax to MNS.
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Instructions: Discharge Planning begins on the first day of patient/resident admission. Please complete and fax this
form beginning with admission and with each update through discharge. If no change occurs by discharge,
resubmit with a signature and date at the bottom of the third page, indicating “no change.”
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)
)
)
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_________________________________________ ____________________ _____________________
Patient Name
Date of Birth
ID #
___________________________________________________ _______________________
Durable Power of Attorney
Phone #
________________________________________________________ __________________________
Durable Power of Attorney/Health Care Attorney
Phone #
__________________________________________
DPOA Name
__________________________________________
DPOA/HC Name
□ Medicaid
□ Secondary Insurance
□ Disability Application
□ Adult Protective Services
□ Private Pay
□ Other
Prior to discharge, please schedule a follow-up doctor appointment for within 14 days of discharge.
______________________________________________________________ ____________________
Physician Name
Appt. Date/Time
______________________________________________________________ ____________________
Physician Address
Office Phone #
___________________________________________________________________________________
Transportation Plans
Are there any barriers to patient following up with appointment?
□ Yes
□ No
If so, please describe: ___________________________________________________________
□ No Change
□ No Change
________________________ ____________________________________
Date
RN/Social Worker Signature
__________________________ ____________________________________
Date
□ No Change
RN/Social Worker Signature
_________________________ ____________________________________
Date
RN/Social Worker Signature
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United Healthcare Referral Process
1. Upon receipt of a United Healthcare (UHC) referral, please call MNS at 800-949-2159, Option #4. An
MNS Care Coordinator Assistant (CCA) will be assigned to your facility. Please fax the needed patient
information to the MNS CCA. The MNS CCA will contact UHC for benefit verification and will fax benefit
information to the affiliated provider.
2. The facility is responsible to call United Healthcare pre-certification department directly for preauthorization of admission and for continued certifications.
a. Please use MNS’ TIN 31-1504075 in all communication with UHC. They will not be able to find
you in their system if you use your own TIN.
b. Pre-certification please call United Healthcare at 877-842-3210.
c. Record the authorization number assigned. MNS will need this information.
d. UHC will not do a retro precertification, so make sure this is completed prior to admission.
e. Request a level of care when initial documentation is sent to United HealthCare.
f. For outpatient therapy, please complete the outpatient form and fax it to MNS with a face sheet
at the beginning of therapy. Please update MNS on a bi-weekly basis regarding continued
treatment and/or discharge from treatment.
3. MNS will contact the affiliated provider once notified of an admission.
a. Complete the Information Sheet when the patient is admitted and fax it back to MNS, with a
copy of the face sheet and front page of the hospital transfer orders to 614-789-2060 within 24
hours of admission. MNS must be notified that the patient is being admitted before the patient is
entered into the MNS systems.
b. Please inform MNS of any authorization for exclusions, such as IV antibiotics, TPN, isolation bed,
and so on. A separate authorization must be obtained for these services from United Healthcare
care coordination.
c. If the patient is not to be admitted, notify MNS as soon as possible.
d. On a weekly basis, update the ongoing certification information to MNS.
4. Notify MNS with any changes (discharge, level change, additional days).
a. If not contacted by the facility, MNS will call the affiliated provider within three (3) days after an
update is due to inquire about the patient’s status.
b. It is very important that MNS receive timely notification of changes and discharges. This affects
billing and can delay payment.
c. Please submit UHC primary claims to MNS.
d. Secondary claims are to be submitted directly to UHC using MNS TIN 31-1504075.
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United Healthcare Documentation—Skilled
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United Healthcare Documentation—Outpatient
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Referral for Part B Services or Outpatient Services
For insurance contracts that cover Part B or Outpatient services through the MNS contract, the following
needs to be done:
1. Complete therapy screen concerning reason for implementation of services.
2. Obtain physician order for services.
3. For an HMO patient, notify primary care and submit a referral as per policy of the insurance contract.
(The PCP may not be the same doctor writing the order—the PCP is the doctor of record with the
insurance company.)
4. Fax the therapy screen, physician order, and patient demographic face sheet to MNS.
5. MNS will obtain the authorization for evaluation and send a copy of benefits.
6. Fax the evaluation and treatment request to MNS.
7. MNS will obtain the authorization as needed for treatment and notify facility.
8. Fax the discharge summary to MNS when therapy is complete.
9. Send an itemized UB-04 claim to MNS for the services provided.
Medicare Exhaust Patient Processing
1. Facility personnel will notify a MNS Care Coordination representative of a 100-day Medicare exhaust
patient preferably three (3) to five (5) days prior to exhaust. (NOTE: MNS will do an authorization via
telephone.)
2. If authorization cannot be obtained, the MNS Care Coordination Assistant will begin the referral and
intake process and will check the patient’s benefit with secondary insurance. MNS will verify the
procedure for certification and claim submission. This process can take up to 10 business days, but is
typically only a few days.
3. The Provider will then submit information for completion of the intake sheet.*
*Refer to Medicare 100-Day Exhaust Claims and Charts Checklist, next page.
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Medicare 100-Day Exhaust Claims and Charts Checklist
Instructions: Please complete this checklist within 24 hours when your patient exhausts the 100-day Medicare skilled benefit and
the patient’s secondary policy becomes primary payor and you are an affiliated provider with MNS. Notify MNS Care Coordination
Department of your patient’s stay approaching their 101st day and fax the following information within 24 hours so that a record
can be started to track the patient in the MNS system, 800-949-2551.
Medicare 100-day Exhaust Claims and Charts Checklist
Demographics
1. Name
2.
Responsible party address
3. Phone number
4. Date of Birth
5. Insurance product and ID number and group number (send copy of insurance card)
6.
The insured’s name if other than the patient
Diagnosis
Skilled needs/services being delivered (i.e., PT, OT, wounds, respiratory, et. al.)
Hospital patient admitted from most recently
Date of most recent hospital admission
Dates of skilled services being submitted for reimbursement
Level of care being requested (time log backup is required for levels greater than level I)
Date that secondary insurance would become primary payor
Attending physician and phone number
Original date of admission to facility
The following items must be submitted on a monthly basis to MNS via mail. This information will be used for medical review and
authorization of claim payment by the insurance payor. Please ensure that the medical record and supporting documentation is
legible.
Copy of Medicare EOB showing the date of exhaustion of the Medicare benefit. (First month only. Essential to
submit in order to have payment processed and released from the insurance company.)
Copy of the itemized UB-04 for the private insurance skilled service billing for the month.
Medical record documentation that includes the following:
Initial evaluations for therapy services
Current status of patient progress for each therapy
Updated goals and plan of care for the patient for each therapy beginning with the 101st day
Initial and current nursing skilled assessment and documentation (i.e., tube feeding, wounds, IV
administration, qualifying medical conditions, pain management, et. al.)
Current physician orders
Current physician progress notes and plan of care
Social service note, discharge planning, and anticipated length of skilled stay
Include time logs for therapy services being delivered and clearly document the level of care that is being
requested (i.e., Aetna: Level I, II, III, IV)
MDS summary
Please label each chart page with the patient’s name
Please submit this medical record information organized and ready for submission to the insurance company. MNS does not
make the determinations of authorization and must send the documentation to the insurer. If you have any questions concerning the information required, contact a care coordinator for assistance 800-949-2159. Affiliated provider must bill the responsible party for the patient s stay starting the 101st day and from that point on until determination of coverage is received from
payor.
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PCP Discharge Appointment Program
Program Purpose: To decrease the frequency of hospital readmissions following a discharge to the
community from skilled nursing care.
Process:
1. Facility social service or discharge planner is to call the patient’s primary care physician or specialist
and schedule an appointment within 14 days of patient’s skilled nursing facility discharge.
2. Upon the establishment of a projected date of discharge in 7–14 days, it is appropriate for the facility
representative to call and make the appointment for 14 days in the future.
3. Document the appointment information on third page of the MNS Skilled Discharge Planning Form.
Complete:
a. physician Name
b. date and time of appointment
c. physician address
d. physician office phone number
e. transportation plans
f. identify barriers that exist for following up with the appointment
Follow Up Doctor Appointment: (Please schedule appointment for within 14 days of skilled discharge prior
to discharge to home.)
Name___________________________________________________________________________________
Date/Time_______________________________________________________________________________
Physician Address_________________________________________________________________________
Office Phone Number__________________________________Fax_________________________________
Transportation Plans_______________________________________________________________________
Are there any barriers to patient following up with appointment?
□
Yes
□
No
4. Fax the completed information to MNS Care Coordination.
5. Complete the Patient/Responsible Party Notification of Physician Follow-up Appointment Form and
send it home with the patient.
6. If the appointment cannot be scheduled, report the reason to MNS Care Coordination.
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Notification Form for Physician Follow-up Appointment
Patient Responsible Party Notification of Physician Follow-up Appointment
Please be advised that your health insurance company, Aetna, has requested a physician follow-up visit be
scheduled prior to your discharge. The appointment will occur within the next 14 days in order for your
physician to meet with you.
Below is a summary of information concerning the appointment date, and transportation plans for your
scheduled visit:
Physician Name: _________________________________________________________________________
Physician Address: ________________________________________________________________________
City, State Zip Code: ______________________________________________________________________
Date: __________________________________ Time:___________________________________________
Transportation Plans: _____________________________________________________________________
Your health care insurance provider may contact you after discharge from our facility.
Thank you for allowing our facility to be of service to you.
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Aetna Home Health Initiative
Program Purpose: To reduce hospital readmissions within 60 days of a SNF discharge to home. To provide
safety visit following a SNF stay in the patient’s home. The focus of the visit will include:
1. Assessment of discharge medications and home medications, and the patient/caregiver’s understanding
of how to administer medications.
2. Assessment of the environment for fall risk situations and other safety issues.
3. Assessment of the care giver situation; provision of education as needed.
The facility is asked to:
1. Contact CSI for Aetna home health referral: 888-873-7888.
2. Document that the CSI has been called for home health services and arrangements have been made per
the MNS Skilled Discharge Planning Form. (When another Aetna home health provider is used, please note
the provider. The patient’s outcome will not be part of the Aetna study unless the provider is part of the
CSI network.)
Aetna Welcome Home Program
Program Purpose: The Aetna Welcome Home Program provides transitional care to members discharged
from an acute care hospital. Univita Health will assist Aetna with administering this program. The goals of the
program are to improve a patient’s quality of care and help prevent avoidable hospital readmissions. The
target group is Aetna Medicare Advantage (MA) plan members who:
1. Are age 65 or over
2. Have an admitting diagnosis in one of the following categories: cardiac, respiratory, fractures, CVD/sepsis
3. Are not in long-term care or in hospice and;
4. Will be discharged from an acute care hospital to home or to a skilled nursing facility (SNF).
Aetna staff will assist Univita Health to identify MA plan members who are eligible for the program. A
Welcome Home nurse from Univita Health will then ask member if they’d like to participate in the program.
Member participation in the Welcome Home Program is voluntary. If the member chooses to participate in
the program, the Univita Health nurse’s role will be to:
1. Obtain information about the member’s plan of care and needs for a safe inpatient discharge, and assist
with coordinating care beyond discharge.
2. Visit the member in the hospital and in the skilled nursing facility, if permitted by the facility. The Univita
Health nurse will discuss with the member his/her condition and discharge plan, and assess the member’s
needs when he/she is discharged and returns home. The Univita Health nurse will also make plans for a
follow-up home visit with the member.
3. Visit the member at least once after he/she is home. The Univita Health nurse will:
a. Review the member’s medication therapies and, as appropriate, recommend that the Aetna case
manager follow up with the member’s physician.
b. Confirm that the member understands his/her care plan and has the support needed to follow the
care plan.
c. Confirm that the member has a follow-up visit scheduled with his/her physician within 14 days of
discharge from the hospital or skilled nursing facility.
d. Request referrals from additional services (i.e., pharmacist consult, social work, et al.), as needed.
Aetna staff will arrange for additional services that are covered under the member’s MA plan.
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The Welcome Home nurse will not arrange for post-hospital or skilled nursing facility (SNF) services.
Additionally, the Welcome Home Program is not a substitute for skilled home care. Members participating in
the Welcome Home program may receive covered services from any skilled home health care provider they
choose, in accordance with their MA plan documents and applicable requirements.
Medicare Advantage Private Fee for Service (PFFS) Admissions
(Medicare Part C)
1. Patient must meet Medicare Guidelines for skilled care admission.
2. Facilities are required to contact MNS Care Coordination services for Network PFFS admissions.
Facilities can contact MNS Care Coordination services for Partial Network and Non-Network PFFS as
well, if an agreement is on file with MNS to do so. (Contact MNS Care Coordination if you are unsure of
your facility’s status.)
3. Notify MNS Care Coordination of referral and the number of Medicare days that have
previously been used if available.
4. MNS will check benefits and notify facility of the requirements for the specific plan. Insurance payors
vary in requirements for case management of patients
5. There is wide variance in the response time of payor case managers returning calls following
submission of requested documentation for PFFS patients.
6. Complete the Notice of Medicare Non-Coverage Letter for all PFFS patients. (See below.)
7. Follow the routine process for Care Coordination as directed.
8. If the payor Case Manager contacts you directly with authorization information, please forward the
information to MNS for accurate record maintenance.
Notice of Medicare Non-Coverage Letter (NOMNC)
1. The NOMNC is a Medicare requirement. Any individual with a Medicare replacement insurance policy
must have adequate notice of their appeal rights for denial of further skilled care. This notice must be
delivered to the patient or responsible party 48 hours prior to discontinuation of services.
2. A facility representative is responsible to present the letter to the patient or responsible party or
document the efforts made to deliver the information in the prescribed time frame.
3. For payors who do not pre-populate the form, the facility can use the template to populate the form.
4. Please do the following:
a. Insert the facility logo
b. Enter the last covered day by insurance
c. Enter the QIO information for your area (page 2)
5. Do not add any other explanations to the form other than those that already appear.
6. Have the patient or responsible party sign the notice (to acknowledge receipt).
7. Place the signed document on the patient chart, and send a copy to MNS.
8. If the patient chooses to appeal and documentation is requested from your facility, this must be turned
around in the time requested. If the request is on a weekend, holiday, or evening hours, make
arrangements to meet the request of the QIO. Specific time frames must be met.
9. In the event the responsible party is notified by phone and unable to sign the form on the date issued,
review the appeal rights, document the contact and that appeal rights have been reviewed. A copy of the
notice should be mailed to the responsible party by certified mail the same day. Document that the
notice was mailed certified. Have the notice signed when the responsible party is able to come to the
facility.
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Reimbursement
Claims Submission
Affiliated Providers are to submit claims for all MNS patients to MNS via U.S. mail, fax, e-mail, or verify
certain claims online at https://providers.casepointe.com.
Submit all claims not available on the MNS portal using one of the below methods:
Claims Processing
Management and Network Services, LLC
5555 Parkcenter Circle, Ste. 200
Dublin, Ohio 43017
E-mail: [email protected]
Phone: 800-949-2159
Fax: 800-949-2551
Claim Form Completion Requirements
Claims are to be submitted on a UB-04 along with a copy of the front and back of the patient’s insurance
card. Please complete all of the applicable areas of the UB-04 as if billing for a “fee for service” (private
pay) or Medicare stay listing total charges in each service area. Use the Room and Board line item to
calculate the per diem rate. Use box 84 to communicate billing and/or unusual claim information. A
completed UB-04 sample is included for your convenience.
Aetna Inpatient Claims
Affiliated Providers having an Aetna contact through MNS are not required to submit a UB-04 for an
inpatient stay with the exception of the Contract Plans. Upon completion of an approved stay or at the end
of each month of the patient confinement, MNS will submit an Aetna Utilization Report to the Affiliated
Provider depicting the dates of service, level(s) of care, and contracted rate of payment. The Aetna
Utilization Report will be marked with the date sent to the facility and in return, the Affiliated Provider will
enter the total charges to the Aetna Utilization Report, verify, and attest the information is correct and fax
the report back to MNS.
The Aetna Utilization Report will be dated as to receipt back from the facility to MNS. Once MNS receives
the Aetna Utilization Report, a claim will be submitted to Aetna based on the information reviewed,
audited, and attested to by the Affiliated Provider. (See sample copy of Aetna Utilization Report, page 58.)
Additionally, these claims will be available on the MNS portal for verification. You may verify claims by
going to https://providers.casepointe.com. If you do not currently have a login for the MNS portal, please
contact your assigned account representative. To find out who your representative is, you may reach our
call center by telephone at 800-949-2159, Option #5.
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Processing all other Aetna Claims
All claims received by MNS for inpatient or outpatient services not approved or authorized by Aetna Patient
Management (PM) are as follows:
1. Claims received for non-skilled services (i.e., custodial, long-term) will be logged, forwarded to Aetna
without further processing by MNS. The Affiliated Provider will be notified that the claim has been
forwarded to Aetna for denial.
2. Claims received from non-Affiliated Providers of MNS for Aetna will be logged, forwarded to Aetna
without further processing by MNS. The non-Affiliated Provider will be notified that the claim has been
forwarded and MNS is not the billing agent for Aetna claims.
3. Outpatient claims approved by MNS will be processed by MNS and submitted to Aetna for payment.
4. Outpatient claims not approved, but received by MNS (i.e., RPN claims), will be logged, forwarded to
Aetna without further processing by MNS. The Affiliated or non-Affiliated Provider will be notified that
MNS is not the billing agent for this service to Aetna.
5. Secondary claims received from Affiliated or non-Affiliated Providers will be logged, forwarded to Aetna
without further processing by MNS. The Affiliated or non-Affiliated Provider will be notified that MNS is
not the billing agent for the provider for secondary claims to Aetna.
Private Fee for Service Claims
Original Medicare claims guidelines and policies apply. Therefore, Private Fee for Service (PFFS) claims are
submitted to MNS by the Affiliated Provider as if billing a claim to Medicare utilizing the RUG classification
system to classify residents for Medicare payment. PFFS claims are not submitted to the contracted payor
until the Affiliated Provider claim is received by MNS. Once the PFFS claim is received, an itemized bill is
generated using a UB 04 billing form. Private Fee for Service claim guidelines apply to all PFFS Plans. Please
contact the Account Representative assigned to your facility with questions regarding Private Fee for
Service claims guidelines.
Inpatient Skilled Care PPO Claims (Fee for Service)
PPO (Fee for Service) Claims are submitted to MNS using detailed itemization of services rendered by the
Affiliated Provider. PPO claims are not submitted to the contracted payor until the Affiliated Provider claim
is received by MNS. Once the claim is received, an itemized bill is generated using a UB-04 billing form. Fee
For Service claim guidelines apply to the following, but are not limited to, Beech Street, Cigna PPO, Emerald,
Ohio Health Choice, Multiplan, NPPN, Cofinity, Molina, and IHG. Please contact the Account Representative
assigned to your facility with questions regarding Fee for Service claims guidelines.
Outpatient Therapy Claims (PTB)
Outpatient Therapy Claims are for Outpatient Therapy services delivered by the Affiliated Providers. There
are two types of Outpatient Therapy claims depending on the payor’s contract:
1. Outpatient claims billed utilizing MNS contracted rates.
2. Outpatient claims billed utilizing the Fee for Service claim received by the Affiliated Providers.
Reimbursement is based on the payor’s fee schedule. See Sample Part B Outpatient Claim.
Outpatient Therapy Claims are not submitted to the payor until the Affiliated Provider claim is received
by MNS. Once the claim is received, an itemized bill is generated using a UB-04 billing form.
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Exclusion Claims
Negotiated exclusions for an inpatient stay:
1. Must be accompanied with a copy of the invoice the Provider received from the company providing
the service (i.e., pharmacy bill, DME bill, et. al.).
a. If the claim is for pharmaceutical charges it must include the National Drug Codes (NDC) and/or J
codes. MNS will be responsible for calculating the Average Wholesale Price (AWP).
Medicare Exhaust Claims
Medicare Exhaust patients are those who exhausted 100 days of the Medicare skilled benefit. On the 101st
day, the secondary insurance product becomes primary. MNS, in return, will forward to the Affiliated
Provider a copy of the Medicare 100-Day Exhaust Claims and Charts Checklist.
Affiliated Provider personnel:
1. Will notify MNS concerning a Medicare exhaust patient.
2. Will send MNS a copy of Medicare Determination of non-coverage.
3. Will send MNS a copy of Medicare notification (advice from Medicare online or remittance advice)
regarding exhaustion of benefits.
4. Will send MNS required legible documentation for submission to insurance payor.
5. Will send MNS an itemized bill for the skilled services rendered.
Note: Until the charges are approved by the payor, they are considered patient responsibility.
Retro Claims
Retro Claims are those claims received by MNS without the Affiliated Provider admitting a patient through
the MNS Care Coordination Services Access Process. Upon receipt of a Retro Claim, the Retrospective
Review Specialist may contact the Affiliated Provider for specific patient information including
eligibility, certification, and payor contact information. A patient encounter is created if the patient stay has
been certified by the primary payor through the Affiliated Provider, and a retro inpatient entry is created
for claims processing. Affiliated Provider payment for all inpatient retro claims will be reduced by 5% due to
the added research and untimely filing. If the claim is denied, the Affiliated Provider is notified in writing
and the denial letter is accompanied with the Payor Denial Notice (EOB). If an Affiliated Provider wishes to
appeal the denial they should contact their MNS Account Representative.
Date of Claim Submission Requirements
Affiliated Providers are to bill MNS by the tenth day of the month for services rendered during the previous
month. Claims are to be billed separately by month and at the end of confinement, unless otherwise
instructed. This billing may include patients who have been discharged during the prior month or those
under continued care. MNS will not be obligated to pay claims submitted after the timely filing limit
designated by the patient’s plan.
Provider Census Reporting
Each month, Affiliated Providers with unbilled inpatient or therapy (PTB) claims are reminded to submit their
claims via the Provider Census Report. MNS will notify the Affiliated Providers by fax each month until the
claim is received.
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Claims Reimbursement
MNS will pay Affiliated Provider claims for covered services within 30 days following receipt of payment
from the member’s primary payor provided the Affiliated Provider claims are accurate, complete in the
agreed upon form, submitted in a timely manner, and do not require further investigation.
Deductibles, Co-pay, and Coinsurance
MNS is not responsible for collecting patient’s deductibles, co-pays, or coinsurance. From time to time,
reimbursement may be less than expected due to the deduction of the patient’s liability. If this occurs, the
MNS Remittance Advice will explain the deduction in detail.
Provider Overpayment
If MNS pays an Affiliated Provider more than is reimbursed by the member’s primary payor, the Affiliated
Provider will be contacted and informed of the overpayment and a “take back” made on the next
scheduled check run. The EOB will clearly state the reason for the “take back” and the dates of service
overpaid. If the Affiliated Provider has no balance due, a refund will be requested from the Affiliated
Provider to be paid to MNS within 30 days of date the overpayment is identified.
Denial of Claims
1. If the claim is denied as custodial care, the Affiliated Provider will be contacted.
2. If the claim is pended for the Medicare EOB, the Affiliated Provider’s business office will be contacted
to request a copy of the Medicare EOB.
3. If the claim is denied because the patient did not have active coverage at the time of service, the
Affiliated Provider will be notified the claim has been suspended.
4. If information is inaccurate or incomplete, the claim will be returned within 24 hours via U.S. mail for
additional information accompanied by an MNS Request for Additional Claim Information form or
follow-up telephone call from an MNS Account Representative.
5. Documented information faxed to MNS from the Affiliated Provider will be accepted as
correcting an incomplete claim. The clean claim will then be processed as accurate.
Claims Call Center and Account Representatives
MNS has a claim call center for facilities to utilize with questions regarding submission of claims or
payment of claims. The claims call center can be reached by dialing 800-949-2159, Option #5. The claims
call center gives the ability to check up to three claims at a time. If you have more than three inquires,
please contact the Account Representative assigned to your facility. If you do not know the assigned
representative for your facility, please contact the claims call center and a Customer Service
Representative will provide the Account Representative’s name and telephone number.
Claim Inquiry
Affiliated Providers may request an update from MNS as to the status of their pending or suspended
claims via fax at 614-789-2068. Requests are responded to within two to three business days.
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Provider Portal
The MNS Provider Portal provides you with all the critical information you need. Contact your Account
Representative at 800-949-2159, Option 5 to ensure that you are able to access the portal.
What You Will Find on the MNS Provider Portal

Facility Demographic Information

Facility Managed Care Contract Administrative Information

Facility Census

Claim Status for all Payor Contracts

Point and Click Billing of Per Diem Claims

Anticipated Release of Payment

Explanation of Payment

EFT Enrollment

837 and PDF claim uploads
Signing Up
1. To gain access to the MNS Provider Portal, you must contact your Account Representative. If you are
unsure of your assigned Account Representative, please call (800) 949-2159, Option 5.

Once you are granted access to the portal, you will receive a link to register and once you register, you
can save https://providers.casepointe.com to your favorites menu.
3. You will receive the Provider Portal User Manual during your initial in-service with MNS, and you can
also access the manual via the MNS website at www.mnsnetwork.com.
57
Doe, John
XYZ Facility and
Rehab
12345-54321
MNS ID#
238.50
Facility Rate
Facility Total
Charges
2,862.00
Facility Total
Payment
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NO NEED TO SEND A UB CLAIM FORM AFTER SIGNING THE AETNA UTILIZATION REPORT.
Signature_____________________________________________________________________________________________
Name _________________________________________________________ Date _________________________________
As a representative of _____________________________, I have reviewed the above information and agree it is correct as
stated.
Please initial any changes made to the above information.
Please make any necessary changes to the above grid if:
1. MNS Patient record and census do not agree with your records
2. Discrepancy in level of care
3. Discrepancy in Dates of Service
4. Any of the above information is inaccurate
Please complete the Facility Total Charges before faxing information to MNS at 800-949-2551 or 614-789-2068.
Patient Name
Facility
Sample Aetna Utilization Report
I
Billing Level
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03/01/2011
Jane Doe
03/31/2011
DOS Thru
31
# of Units
Aetna-Local Medicare PPO
Payor Name-Product
59
Fax your claims to: 614-789-2068 or
E-mail your claims to: [email protected] or
Mail your claims to 4892 Blazer Parkway, Dublin, OH 43017 Attn: Claims (Note: As of April 1, 2014, mail your claims to
5555 Parkcenter Circle, STE 200, Dublin, OH 43017
02/01/2011
Jane Doe
02/28/2011
DOS Thru
28
# of Units
Aetna-Local Medicare PPO
Payor Name-Product
Yours in Service,
Account Representative Department
Should you have any questions or concerns, please contact MNS at 800-949-2159, Option 5 and a representative will assist you.
DOS From
Patient
*Past Due Claims*
Additionally, below is a summary of patients for previous months in which we still have not received a claim. Please send the claim to MNS as
soon as possible so we may submit to the payor for payment.



Please send claims to MNS as promptly as possible so we may bill the claim to the payor and decrease the payment turnaround time.
DOS From
Patient
Dear Business Office Manager,
According to Management and Network Services (MNS), your monthly census for month ending 3/31/2011 is below.
ABC Nursing Home
Attn: Business Office Manager
3780 ABC Boulevard
Fax: 440-934-6388
Sample Provider Census Report
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Glossary
Accountable Care Organization (ACO)—Group of doctors, hospitals, and other health care providers who come together
voluntarily to give coordinated quality care to specific patients, most often Medicare patients.
Accreditation—Approval by an authorizing agency for institutions and programs that meet or exceed a set of pre-determined
standards.
Adjudication—Processing a claim through a series of edits to determine proper payment.
Aetna Utilization Report (AUR)—Monthly report sent to facilities detailing the Aetna per diem claims that MNS expects to
receive and bill for the month.
Affiliated Provider—A contracted and credentialed facility which is a network member in good standing.
Affordable Care Act—Federal Patient Protection and Affordable Care Act, sometimes known as Obamacare.
Allowable charges—The specific dollar amount of a medical bill that Medicare, Medicaid, or the patient’s health plan will pay.
Benefits exhaust—After a patient has used the skilled nursing allowable number of care days through their payor, their benefits
exhaust. When this happens, the patient is no longer considered eligible for coverage through their primary care insurance.
Occasionally they will have secondary cover that they can use. Another option is to continue skilled services and pay for them
privately (100% out of pocket for patient or family).
Benefits verification—Verifying patient’s benefits with patient’s insurance provider for services that are ordered or required.
Break in Stay—This occurs when a patient leaves the facility for any reason for more than 24 hours (including being admitted to
a hospital).
CMS—Centers for Medicare and Medicaid Services.
Capitation—A payment method in which the provider agrees to provide all the care the patient may need in return for a fixed
monthly payment by the payor (patient’s health care plan).
Case Manager—A health care professional who monitors the allocation and coordination of a patient’s overall care.
Co-insurance—The percentage of covered services that an insurer will pay after the insured individual meets the deductible.
Contracted Payor—A payor that is in contract with MNS to provide services.
Coordination of Benefits (COB)—The process of determining which health plan or insurance policy will pay first when a
Medicaid beneficiary is covered by multiple health care insurers. Together, the health plans cannot pay more than the charge for
the services.
Copay—The fixed dollar amount that is due from the insured individual at the time a covered service is provided.
Corporate Compliance—The implementation of executed, contractual obligations.
Covered Service—Services reimbursable by enrollee’s insurance policy.
Credentialing—The process of reviewing a practitioner’s academic, clinical and professional ability as demonstrated in the past
to determine if criteria for clinical privileges are met.
Date of Service (DOS)—The date that a service or services are rendered to a beneficiary.
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Glossary
Deductible—The expense for covered services that the insured individual must pay before the insurer will assume any liability
for all or part of the remaining cost. Not all health plans require deductibles.
Denial of care—A refusal by a managed care plan to cover a specific test or treatment.
Discharge date—The actual date the patient is discharged from a skilled nursing facility. The facility is not paid on the discharge
date
Discharge Planning—The evaluation of patient’s health needs for appropriate care after discharge from an inpatient setting.
Dual Eligible—A person who qualifies for two health insurance plans, often referring to a Medicare beneficiary who also qualifies
for Medicaid benefits.
Durable Medical Equipment (DME)—Equipment that can withstand repeated use, such as an oxygen machine or hospital bed.
Durable Power of Attorney—A document in which individuals select another person to act on their behalf in the event they
become incapacitated
Electronic Funds Transfer (EFT)—A system of transferring money from one bank account directly to another without any paper
money changing hands.
Electronic Health Record (EHR)—An individual medical record of diagnoses, treatments, and laboratory results that has been
stored electronically for use by authorized treatment professionals.
Eligible Claim—Claims in which a patient’s stay has been authorized by MNS Case Management Services.
Encounter—The patient’s case file in CasePointe.
Explanation of Benefits (EOB)—A statement sent from a health insurance company to the insured individual listing the services
that were billed by a healthcare provider, how the charges were processed, and the total amount of patient responsibility for
the claim.
Explanation of Payment (EOP)—A statement that provides detail on claims that have ben paid, denied, or adjusted.
Face Sheet—Cover sheet provided by the hospital or facility that shows managed care declaration of health insurance and
patient demographic information.
Grandfathered Health Plan—A group health plan in existence on March 23, 2010, that meets specified requirements and is
exempt from certain health reform requirements.
Grievance—A complaint brought to the administration of a managed care plan by a plan member. The complaint may pertain to
quality of care issues, a plan coverage decision, or financial issues, such as a dispute between the plan and the member over
how much the plan has paid for a particular health care product or service.
HCFA 1500—Health Care Financing Administration (Medicare) claim form used to bill outpatient charges.
Health Insurance Portability and Accountability Act (HIPAA)—A federal law that includes requirements to protect patient
privacy, to protect security of electronic medical records, to prescribe methods and formats for exchange of electronic medical
information, and to uniformly identify providers.
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Glossary
Health Maintenance Organization (HMO)—An HMO is a nonprofit organization that provides comprehensive health
maintenance services, or arranges for the provision of these services, to enrollees on the basis of a fixed prepaid sum without
regard to the frequency or extent of services furnished to any particular enrollee.
HHS—The U.S Department of Health and Human Services.
History and Physical (H&P)—Form used to obtain the patient’s family and personal medical history.
Integrated Care Delivery System (ICDS)—A system of managed care plans selected to coordinate the physical, behavioral, and
long-term care services for individuals over the age of 18.
Incomplete Claim— A claim in which some of the required information is missing.
Intake—documentation tool used to record interactions with insurance payor and patient evaluation information.
Last Covered Day (LCD)—The last financially covered day of a patient’s encounter; not the discharge date.
Leave of Absence (LOA)—A patient may leave the nursing facility for less than 24 hours for an observation status at a hospital.
The patient would not be formally admitted to the hospital. Some payors will continue an authorization and not require a break
in stay.
Length of Stay (LOS)—The total number of days that a patient stays in a facility.
Letter of Agreement (LOA)—This is essentially a mini contract or document outlining the rate that the payor has agreed to pay
for a particular patient.
Level of Care (LOC)—The intensity of care provided to patients in a skilled nursing facility. Each insurer defines these levels of
care differently. Level of care determines the reimbursement of room and board per day based on a level 1–3 possible 4 for each
encounter.
Late admission—When a patient has already been admitted, but not discharged from a skilled service facility.
Lifetime Maximum— The maximum dollar amount of benefits available to a consumer in a managed care plan.
Living Will— A legal document that outlines an individual’s desired medical care in cases in which the individual is no longer able
to articulate his or her own wishes.
Long-Term Care (LTC)—A set of health care, personal care, and social services (not skilled nursing care) provided to persons who
have lost, or never acquired, some degree of functional capacity. This care is administered at an institution or at home on a longterm basis.
Managed Care—The coordination of all healthcare services received in order to maximize benefits and minimize costs. Managed
care plans use their own network of health care providers and a system of prior approval from a primary care doctor. Providers
include specialists, hospitals, skilled nursing facilities, therapists, and home health care agencies.
Medicaid—A state-funded healthcare program for low income and disabled persons.
Medical Appeal—Claims which are to be reviewed by the contracted payor per the request of assignment).
Medicare—A national, federally administered health insurance program that covers the cost of hospitalization, medical care,
and some related health services for most people over age 65 or those with certain disabilities.
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Medicare Exhaust—If a patient has Medicare Primary and has used the 100 days of skilled nursing care, they may qualify for
additional days of care through their secondary payor. If the patient has a skilled benefit through their secondary payor,
documentation is needed to show the Medicare Exhausted. This then would not be considered secondary billing.
Medicare Part B (PTB)—The part of Medicare coverage that pays for doctor services, outpatient hospital care, clinical laboratory
and diagnostic services, surgical supplies and durable medical equipment, ambulance services, and other medical services that
are not covered by the Part A form.
Medigap—This is a supplemental Medicare health insurance plan that pays for some of the deductibles and coinsurance for
which Medicare beneficiaries are responsible. Medigap insurance plans also may cover some additional services not covered by
Medicare, such as prescription drugs. Medicare beneficiaries who want Medigap insurance must purchase it themselves and pay
a monthly premium for it.
Medical Loss Ratio (MLR)—The percent of premium that a payor spends on claims and expenses for a patient.
MedPAC—Medicare Payment Advisory Committee.
Minimum Essential Coverage (MEC)—This is the level of coverage an individual needs to have to meet the individual
responsibility requirement under the Affordable Care Act.
Notice of Medicare Non-Coverage Letter (NOMNC)—This letter informs the patient that Medicare will not pay for further skilled
care after a specified date. The NOMNC letter can also be used for Medicare Replacement policies.
Non-Affiliate Provider—A facility that is not a member of the network.
Non-Contracted Payor—A payor that is not contracted with MNS.
Outpatient— A patient who receives services in a healthcare facility and goes home the same day.
Payor—Insurance company that financially reimburses a skilled nursing facility for care expenses (i.e., Aetna).
Pended Claim—Claims which are awaiting payment from the primary payor.
Per diem—A single charge for a day in the facility regardless of any actual charges or costs incurred. The payor bills on a per
diem basis.
Physical Therapy/Outpatient Therapy (PT/OT)—Record of therapy services rendered during a patient’s hospital stay directly
prior to skilled nursing facility admission.
Preadmission certification—Prior approval by a managed care plan to admit a patient to a hospital for medical treatment,
testing, or surgery.
Precertification (Pre-Cert)—The prior approval of admission to a skilled nursing facility for skilled care. May also be referred to
as preadmission certification.
Preferred Provider Organization (PPO)—A large group of hospitals and physicians under contract to a managed care plan.
Health care providers in the PPO serve plan members for negotiated fees and copayments. Plan members who use providers not
in the PPO face higher out of pocket costs.
Prior Authorization (PA)—A requirement that a provider justify the need for delivering a particular service in order to receive
reimbursement. Imposed by a health plan or third-party administrator.
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Glossary
Private Fee for Service (PFFS)—This is a type of Medicare Advantage plan offered by private insurance companies under
contract with Medicare.
Provider—Any of the following: specialists, hospitals, skilled nursing facilities, therapists, and home health care agencies.
Provider Census Report (PCR)—Monthly report sent to facilities detailing all claims that MNS expects to receive and bill for the
month as well as any outstanding claims from all prior encounters.
Retro Claim—This type of claim is generated when a facility admits a patient without first going through the MNS Care
Coordination services access process. Part A retro claims are charged a 5% retro fee for the added research and effort in
rebuilding the case. The retro fee is not applied to Part B claims
Resource Utilization Groups (RUG) classification—A system used to classify all residential, chronic care, and rehabilitation
patients. Patients are classified into RUGs based on their condition and the care they receive at a facility. A value is assigned to
the RUG classification, which is then used to calculate the daily rate of payment for the patient’s care.
SBC—A summary of benefits and coverage summarizing health plan or health insurance governed by health reform.
Satisfaction Survey Interview—A personal interview with a customer to evaluate their experience with the company.
Satisfaction Survey Tool—A printed survey used to evaluate a customer’s experience with the company.
Skilled Care—A level of care that requires the training, skills, and 24-hour-a-day supervision by licensed health care professionals
who are under the direct supervision of a physician. The goal of skilled nursing is to restore the patient to the highest point of
recovery possible. It includes rehabilitation, but not restorative care or maintenance care.
SNF—Skilled nursing facility.
TPA/Third Party Administrator—A TPA will have a contract through a primary payor (example: UHC), but the benefit, rates, precert r billing may be through the TPA (example: UMR)
TPN (Total Parenteral Nutrition)—This is an intravenous feeding that provides nutrition and fluids for someone who cannot take
in foods and fluids orally. It is used on a short-term basis.
UB-04 Claim Form—Universal Billing claim form is used by hospitals and other institutional providers to bill government and
commercial health plans.
Unbilled Claim—Claims that are expected/authorized but haven’t been received. MNS creates an open A/P and A/R file when a
patient file is created, therefore we know in advance of being billed by our affiliate of what our cost will be for each day of
service.
Waiver (home and community based) Programs—Medicaid home and community-based services waivers allow people with
disabilities and chronic conditions to receive care in their homes and communities instead of in long-term care facilities,
hospitals or intermediate care facilities. Waivers allow individuals with disabilities and chronic conditions to have more control
of their lives and remain active participants in their community.
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70
Credentialing
Quality Compliance
Phone: Option 6
Fax: 614-789-2065
[email protected]
Provider
Compliance
5555 Park Center Circle, STE 200 │ Dublin, Ohio 43017 │ www.mnsnetwork.com │ providers.casepointe.com
Facility Claim Logging
Payor Claim Status
Payment Status
Accounts Receivable
Management
Reimbursement
Phone: Option 5
Fax : 614-789-2068
[email protected]
Phone: Option 4
Fax: 614-789-2060
[email protected]
Patient Admission/Discharge
Initial Evaluation
Pre-Certification
Patient Updates and Re-Certification
Change in Condition/Incident Reporting
Referral for Outpatient or Part B
Medicare Exhaust
Discharge Planning
Account
Representatives
Care
Coordination
Mon - Fri 9am - 6pm EST
Phone: 800-949-2159
Fax: 800-949-2551
Management and Network Services, LLC
Quick Reference Guide
Management and Network Services, LLC
Credentialed Provider Manual
71
Credentialing
Quality Compliance
Phone: Option 6
Fax: 614-789-2065
[email protected]
Provider
Compliance
5555 Park Center Circle, STE 200, Dublin, Ohio 43017 │ www.mnsnetwork.com │ providers.casepointe.com
Facility Claim Logging
Payor Claim Status
Payment Status
Accounts Receivable
Management
Reimbursement
Phone: Option 5
Fax: 614-789-2068
[email protected]
Phone: Option 4
Fax: 614-339-4311
[email protected]
Patient Admission/Discharge
Initial Evaluation
Pre-Certification
Patient Updates and Re-Certification
Change in Condition/Incident Reporting
Referral for Outpatient or Part B
Medicare Exhaust
Discharge Planning
Account
Representatives
Care
Coordination
Phone: 800-949-2159
Fax: 800-949-2551
Mon - Fri 9am - 6pm EST
Management and Network Services, LLC
Texas Quick Reference Guide
Management and Network Services, LLC
Credentialed Provider Manual
Management and Network Services, LLC
Credentialed Provider Manual
The Management and Network Services, LLC Credentialed Provider Manual is a product of Management and
Network Services, LLC. Nothing in this manual may be reproduced without the express written permission of
Management and Network Services, LLC. © All rights reserved.
Contact Information:
Management and Network Services, LLC
5555 Parkcenter Circle, STE 200
Dublin, Ohio 43017
Phone 800-949-2159
Fax 800-949-2551
www.mnsnetwork.com
72